DAEEACH 


I».ffiMDEANDUl«i  ON  THE 
SCHOOL  OF  i&;DICi:iI 


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MEMORANDUM 


ON 


THE  SCHOOL  OF  MEDICINE 


BY 

WILLIAM  DARRACH 

Dean  of  the  College  of  Physicians  and  Surgeons 
Columbia  University 


New  York,  December  13,  1919 


y'^T' 


I.  The  Objects  of  the  School  of  Medicine  of  Columbia  Uni-   Objects 
versity  shall  be: 

(a)  to  train  men  and  women  to  be  physicians  of  the  highest 
type  and  to  develop  leaders  of  medical  thought; 

(b)  to  test  and  increase  our  knowledge  of  the  art  and  sci- 
ence of  medicine  and  to  foster  research; 

(c)  to  apply  that  knowledge  to  the  prevention,  cure  or  alle- 
viation of  human  ills. 


Immediate 

Essentials 


Later 
Develop- 
ments 


II.  In  planning  for  such  a  school  we  must  differentiate  be- 
tween that  portion  of  the  entire  scheme  which  is  essential  for 
the  development  of  a  medical  school,  designed  to  accommodate 
a  definite,  number  of  students  for  the  degree  of  M.D.,  and 
other  portions  not  essential  to  this  primary  purpose,  but  neces- 
sary to  complete  the  organization  in  its  fullest  possibilities. 

Such  subdivision  can  be  illustrated  by  two  concentric  circles. 
In  the  smaller  circle  would  be  included,  besides  the  school  and 
laboratories,  a  general  hospital  and  dispensary  of  sufificient 
size  to  supply  the  clinical  material  necessary  for  research  and 
the  undergraduate  teaching. 

In  the  krger  circle  would  be  included  special  hospitals  or 
institute'     ir  the  better  development  of  the  special  branches. 

For,  present  we  shall  deal  only  with  the  smaller  circle, 
leavi'         le  outlying  portion   for   further  consideration. 

/        To  institute  and  carry  on  such  a  school  of  medicine  it    Need.' 
/        essary  to  obtain : 

..  jnd  sufficient  in  amount  to  accommodate  the  various  build- 
ings required  at  present  and  to  allow  for  future  development. 
The  site  should  be  convenient  to  clinical  material  and  to  the 
various  methods  of  transportation  of  the  city. 

Buildings  to  accommodate  the  various  departments  of  the 
school,  the  laboratories,  hospital,  dispensary  and  dormitories 
for  the  students.  These  units  must  be  so  arranged  as  to  allow 
the  intimate  correlation -and  coordination  of  teaching,  research 
and  care  of  the  sick  so  necessary  for  the  full  development  of 


Land 


Buildings 


1 


Limited 
Numbers 


Expansion 


Quality 


.each.  The  school,  hospital,  dispensary  and  laboratories  are  so 
interdependent  that  their  unity  must  be  realized  geographically 
as  well  as  functionally. 

Endowment  sufficient  to  make  it  possible  for  the  University 
to  carry  the  greatly  increased  medical  school  budget  involved 
in  the  proposed  plan  of  organization. 

IV.  The  Medical  School 

1.  The  Student  Body.    Numhers 

The  natural  desire  on  the  part  of  a  university  is  to  accommo- 
date as  many  properly  qualified  students  as  apply  to  the  insti- 
tution. But  in  the  teaching  of  medicine  it  must  be  accepted 
that  there  is  a  definite  limit,  beyond  which  a  single  unit  cannot 
expand  without  lowering  the  quality  of  the  instruction  given. 
When  the  demand  sufficiently  exceeds  this  limit  it  should  be 
met  by  duplicating  the  unit,  rather  than  by  crowding  the  facili- 
ties. It  is  believed  that  today  such  a  limit  is  reached  when  a 
single  class  reaches  100. 

It  is  more  difficult  to  expand  in  the  later  clinical  years,  when 
facilities  depend  on  hospital  bed  capacity,  than  it  is  in  many 
of  the  laboratory  courses  in  the  first  two  years.  For  this 
i^eason  the  number  admitted  to  the  first  two  years  should  not 
exceed  the  accommodations  of  the  later  years.  It  should  not 
be  taken  for  granted  that  a  certain  percentage  of  those  enter- 
ing will  fail  to  qualify  for  advancement,  but  it  should  be  pos- 
sible always  to  carry  through  to  graduation  all  who  are  al- 
lowed to  enter  if  their  work  is  satisfactory.  Vacancies  will 
ahvays  probably  occur  and  these  can  be  well  filled  by  admit- 
ting to  advanced  standing,  students  from  other  schools  who 
may  prove  their  fitness  by  proper  tests. 
Quality 

The  quality  of  the  applicants  for  admission  will  naturally 
improve  with  the  quality  of  the  teaching,  and  the  general 
reputation  of  the  school.  And  it  should  be  possible,  with  a 
limitation  of  numbers,  to  select  those  who  are  best  qualified 
for  the  work.  Such  a  selection  must  be  made  with  great  care. 
It  may  soon  be  necessary  to  require  three  instead  of  the  present 
two  years  of  academic  work,  which  must  include  a  sufficient 
amount  of  physics,  chemistry,  biology,  French  or  German  and 
English.     But  other  methods  must   also  be   devised   for  the 


determination  of  a  candidate's  fitness  for  the  study  of  medi- 
cine. His  mental  and  personal  qualification  may  be  tested  by 
a  psychological  examination  and  his  record  in  his  pre-medical 
work  should  be  taken  into  account. 

2.  Officers  of  Instruction. 

The  success  of  such  an  institution  will  depend  more  on  the 
character  of  the  teaching  body  than  upon  any  other  one  factor.    Selecf  o 

The  selection  and  further  development,  not  only  of  the  heads 
of  the  departments  but  also  of  their  associates  and  assistants, 
must  be  matters  for  the  exercise  of  the  greatest  care  and 
wisdom. 

In  their  selection,  the  three-fold  purpose  of  the  institution — 
teaching,  research  and  the  application  of  knowledge — must  be 
borne  in  mind.  In  making  appointments,  irrespective  of  the 
grade,  every  attempt  should  be  made  to  find  and  obtain  the 
best  available  man  for  the  position,  wherever  he  may  be. 
After  carefully  canvassing  all  possibilities,  expert  advice  should 
be  sought  from  outside  the  institution  before  the  decision  is 
made. 

The  character  of  the  teaching  personnel  will  depend  also  on 
the  opportunities  ofl:'ered  them.  This  includes  both  a  proper 
salary  and  facilities  for  work.  The  former  should  be  adjusted  ^^'^''^' 
to  the  needs  of  the  individual.  For  the  full-time  worker,  whe- 
ther he  be  in  a  laboratory  or  a  clinical  department,  the  salar\- 
should  be  sufficient  to  free  him  from  the  necessity  for  outside 
employment.  For  the  part-time  worker  whose  main  income 
is  derived  from  other  sources,  the  salary  need  be  much  less. 
But  all  men  who  are  actually  engaged  in  teaching  should,  if 
possible,  have  some  financial  reward  in  addition  to  the  honor 
and  respect  the  position  brings. 

Of  more  importance  than  salary  for  either  type  of  man  is 
the  proper  arrangement  of  his  work,  so  that  he  shall  be  freed  Arrangement 
from  unessential  details  and  useless  waste  of  time.    In  the  end  ^'^  Work 
the  opportunity  to  carry  on  teaching  and  research  under  whole- 
some conditions  is  the  most  eflfective  force  for  bringing  into 
the  medical  school  men  of  ability  and  ideals. 

3.  Organization. 

The  School  and  hospital  should  be  organized  and  adminis-    Balanced 
tered   so   as   to   include  men   who   are   qualified   in   all   three   Personnel 


branches — teaching,  research  and  the  application  of  knowledge 
to  the  care  of  the  sick.  Each  individual  need  not  possess  all 
three  qualifications,  but  all  must  be  represented  and  balanced 
throughout  the  school. 

There  should  also  be  such  cooperation  and  coordination 
not  only  within  each  department  but  between  the  different  de- 
partments as  will  weld  them  all  together  into  a  single  well 

balanced  unit. 

(a)  Laboratory  Department. 

The  heads  of  many  of  these  departments  have  long  been 

on  the  full-time  basis  and  with  no  legislation  they  have  volun- 

Fuff-Th^r^^"  tarily  refrained  from  any  outside  employment.     The  results 

Plan  in  the  advancement  of  knowledge  have  proved  the  value  of  such 

an  arrangement. 

There  must  be  no  curtailment  of  the  fields  of  investigation 
in  these  departments.    They  must  be  free  to  study  and  develop 
fnvesdgldon      any  part  of  their  particular  science.     At  the  same  time  they 
but  Teaching     should  consider  their  problems  from  the  standpoint  of  medi- 
CoTrehted  cine  as  a  whole.    They  must  remember  that  they  are  primarily 

parts  of  a  medical  school  and  a  hospital  for  the  sick,  lest  their 
teaching  lose  that  vital  contact  with  medicine  which  is  so  es- 
sential to  the  best  development  of  its  art  and  science. 

This  better  cooperation  will  be  greatly  aided  by  the  geo- 
graphical union  of  the  laboratories  and  the  hospital  and  there- 
fore with  the  clinical  departments.  It  can  also  be  helped  by 
including  among  the  lower  grades  of  their  personnel,  men 
who  are  being  trained  for  the  clinical  departments.  By  serving 
a  limited  time  in  several  of  the  laboratory  branches,  the 
younger  men  will  gain  a  wider  and  firmer  foundation  for  their 
cHnical  work.  This  arrangement  has  long  existed  in  the  Ana- 
tomical Department  and  a  large  percentage  of  the  Surgical 
personnel  are  serving,  or  have  served,  as  demonstrators  of 
anatomy  for  two  to  ten  years. 

(b)  Clinical  Department. 

The  main  clinical  departments  shall  be  reorganized  on  the 

full-time  basis, — Medicine  and  Surgery  immediately  and  Pedi- 

Full-Time  atrics  as  soon  as  financial  and  clinical  facilities  permit.     It  is 

hoped  that  other  departments  may  later  be  similarly  arranged. 

At  the  head  of  each  shall  be  placed  a. man  of  such  training, 


ability  and  character  that  he  may  assume  full  responsibility 
for  and  the  direction  of  the  general  policies  of  the  department, 
the  character  of  the  teaching,  the  hospital  service  and  the 
nomination  of  his  associates.  It  shall  be  his  duty  to  develop 
a  modem  clinic  of  the  best  type. 

Before  considering  further  the  organization  of  these  de- 
partments, the  following  discussion  of  the  ''full-time"  plan 
seems  warranted  by  the  existing  ambiguity  of  the  term,  a? 
evidenced  by  the  widely  divergent  plans  of  organization  now 
in  force  or  planned  throughout  the  country. 

In  the  earlier  days  of  medical  education,  practitioners  gave 
a  portion  of  their  time  to  teaching.  At  first  a  student  became 
associated  with  a  practising  physician  who  gradually  taught 
him  in  all  branches  of  the  art. 

Later  schools  were  formed  where  physicians  concentrated 
their  efforts  on  one  branch  of  the  subject. 

At  another  period  it  was  realized  that  if  teachers  were  to 
keep  abreast  of  the  knowledge  of  the  day  and  to  make  any 
independent  advances,  it  was  necessary  for  them  to  devote 
most  of  their  time  to  investigation  and  teaching  in  their  own 
particular  branch.  This  plan  of  concentrated  effort  was  first 
adopted  in  the  laboratory  branches  and  for  a  number  of  years, 
the  leaders,  and  most  of  their  assistants,  in  the  department? 
of  Anatomy,  Chemistry,  Physiology,  Pathology  and  Bacteri- 
ology, have  been  men  who  have  completely  given  up  or  have 
never  entered  the  practice  of  medicine.  The  results  in  the 
betterment  of  teaching  and  in  the  advancement  of  knowledge 
have  well  proved  the  wisdom  and  necessity  of  such  an  arrange- 
ment. 

Lately  a  similar  development  has  been  taking  place  in  the 
clinical  departments.  In  several  medical  schools  the  depart- 
ments of  Medicine,  Surgery  and  Pediatrics  are  being  reorgan- 
ized on  what  is  spoken  of  as  the  "full-time"  or  "university" 
basis.  It  is  being  widely  accepted  that  such  an  arrangement  is 
necessary  for  the  best  type  of  teaching,  for  the  most  success- 
ful clinical  investigation  and  for  the  most  skillful  care  of  the 
sick. 

The  essential  principle  of  this  arrangement  is  that  the  domi- 
nating group  of  men  in  the  main  clinical  departments  must  be 
free  to  concentrate  their  energies  on  their  university  and  hospi- 


Head  of 
Department 


Discussion  of 

FuU-Time 

Plan 


Apprentice 
System 


Schools 


Full-Time  in 
Laboratory- 
Department 


Details  of 
Organization 


Limitation 


tal  work.  There  are  two  main  factors  which  tend  to  inter- 
fere with  this  freedom,  no  matter  how  sincere  the  intentions 
of  the  men  may  be.  These  factors  are  insufficient  assistance 
and  the  distractions  of  private  practice.  By  providing  the  full- 
time  men  with  sufficient  assistance,  professional,  clerical,  tech- 
nical and  menial,  he  may  relieve  himself  of  such  unnecessary 
details  as  he  desires.  He  must  also  be  protected  from  the  de- 
mands of  private  practice.  The  main  purpose  is  to  obtain  a 
more  truly  university  type  of  clinical  teacher.  The  full-time 
plan  is  a  means  to  this  end — a  method  by  which  it  may  be 
obtained.  Neither  the  time  element  nor  the  question  of  fees 
is,  in  itself,  the  essential  point,  and  these  must  not  be  con- 
founded with  the  primary  object. 

There  is  apparently  but  little  question  in  the  minds  of  medical 
educators  as  to  the  wisdom  and  necessity  of  this  main  prin- 
ciple. There  is,  however,  some  doubt  and  much  discussion 
concerning  the  details  of  organization.  This  is  evidenced  by 
the  wide  variation  among  the  plans  now  in  force  and  among 
others  suggested.  The  main  difficulty  lies  in  the  question  of 
private  practice.  As  a  man's  value  as  a  clinician  increases, 
the  demands  made  for  his  services  by  the  public  naturally  in- 
crease. If  this  increasing  demand  is  satisfied  he  will  have 
less  and  less  time  for  his  university  duties.  It  therefore  be- 
comes necessary  for  these  men  to  control  the  amount  of  pri- 
vate practice  they  shall  do  and  the  conditions  under  which 
it  is  done. 

The  various  so-called  full-time  plans  may  be  sutfimarized 
as  follows : 


Summary 
of  Plans 


Plan  1.  No  private  practice  and  no  outside  employment. 

Plan  2.  Private  practice  at  the  discretion  of  the  clinician  but 
no  fee  is  paid  for  such  service. 

Plan  3.  As  in  Plan  2  except  that  the  fee  is  paid  to  the  Uni- 
versity. 

Plan  4.  Private  practice  for  fees  allowed  in  such  limited 
amounts  that  it  does  not  interfere  with  the  thorough, 
efficient  and  sincere  fulfillment  of  his  academic  duties. 


Plan  5.  Unlimited  private  practice  within  the  hospital. 


Plan  1  has  not  been  tried.  Plan  2  is  in  effect  at  the  Rocke- 
feller Hospital  and  is  the  plan  that  will  be  recommended  in  this 
memorandum.  Plan  3  is  applied  at  Johns  Hopkins.  Plan  4 
is  in  effect  in  several  schools.  Plan  5  was  suggested  in  1911 
but  it  is  not  in  eff'ect. 

From   an  administrative   standpoint  Plan   1   would   be  the    Discussion 
simplest  method.     The  full-time  men  would  limit  their  clinical   °^  ^'^"  ^ 
experience  to  the  wards  of  the  hospital  and  the  dispensary. 
It  seems  unwise  to  deprive  the  public  of  these  men's  services, 
for  patients  who  are  not  eligible  for  the  charity  wards  are  at 
times  of  great  scientitic,  educational,  or  humanitarian  interest! 

Plans  2  and  3,  where  practice  is  restricted  by  removing  the    pians  2 
financial  inducement,  remove  the  above  objection.     The  pay-   ^^^  ^ 
ment  of  the  fee  to  the  University,  however,  is  strongly  criti- 
cised by  many  men  and  is  not  entirely  satisfactory  to  some 
of  the  men  who  have  been  working  under  that  arrangement. 
Of  the  two,  therefore.  Plan  2  seems  to  be  the  preferable  one. 

If  Plan  4  were  used  the  hospital  would  place  a  limited  num-  pjan  4  ' 
ber  of  private  rooms  with  office  facilities  at  the  disposal  of 
men  working  on  this  basis.  These  men  could  then  spend  a 
large  part  of  if  not  all  of  their  time  in  the  school  and  hospital. 
This  plan,  however,  cannot  be  combined  with  Plan  2  without 
introducing  a  discordant  element  into  the  situation.  The 
specific  plan  to  be  proposed  for  adoption  therefore  discards 
men  on  the  Plan  4  basis. 

Plan  5  is  the  one  suggested  by  the  Faculty  of  the  College  of    pj^^^^  5 
Physicians  and  Surgeons  in  1911  but  does  not  meet  the  re- 
quirements of  today,  as  with  unlimited   facilities  within  the 
hospital  such  private  practice  might  well  claim  the  major  por- 
tion of  a  man's  attention. 

These  five  variations  have  all  been  spoken  of  as  "Full-time" 
plans.  Plans  1,  2  and  4  are  consistent  with  the  present  statutes 
of  Columbia  University  as  to  full  time  service. 

The  success  of  any  plan  will  depend  on  the  character  of  the    Character  of 

man  in  question  and  the  spirit  of  the  school.     Any  form  of    ^  ^  t^^"  °^ 

legislation  will  be  unavailing  if  the  wrong  men  are  appointed    Importance 

to  these  positions.     There  are  manv  forms  of  distraction  be-    t      •  \„t.-^ 
_^  _  _'  i^egislation 

sides  private  practice,  especially  in  New  York  City,   which 
might  lure  a  man  from  proper  fulfillment  of  his  academic  du- 


ties.     Some  definite  conception,  ho\Yever,  is  necessary  in  for- 
mulating any  such  reorganization. 

Specific  Plan  Proposed. 

The  fundamental  principle  upon  which  these  departments 
shall  be  reorganized  is  that  the  control  of  each  main  clinical 
department  shall  be  vested  in  a  director,  associated  with  a 
differentiated  group  of  men  who  are  devoting  all  their  time 
to  the  school  and  hospital,  that  they  may  build  up  and  main- 
tain a  department  where  the  best  intensive  clincial  investiga- 
tion and  scientific  research  may  be  carried  on  with  the  teach- 
ing of  students  and  the  care  of  the  sick. 

In  order  to  achieve  this  end  it  is  believed  to  be  wisest  so  to 
organize  these  departments  that  the  director  with  all  of  his 
associates  (those  in  charge  of  portions  of  the  hospital  service) 
and  as  many  of  his  other  assistants  as  he  desires  and  can  af- 
ford, shall  be  on  the  basis  of  Plan  2.  They  would  see  private 
patients  at  their  discretion  for  scientific,  educational,  humani- 
tarian or  personal  reasons  and  when  they  do  no  fee  would 
be  paid  for  such  service.  The  head  of  the  department  shall 
not  only  be  responsible  for  the  general  policies  of  the  whole 
•department,  for  the  character  of  the  teaching  and  for  the  nomi- 
nation of  his  associates,  but  he  shall  be  given  every  facility 
to  develop  a  well-rounded,  modern  clinic,  with  sufficient  clini- 
cal material  in  both  wards  and  dispensary,  with  the  specialized 
assistants,  professional,  clerical  and  menial,  he  requires  and 
the  necessary  laboratories. 

To  carry  on  efficiently  the  teaching  of  two  classes  of  100 
men  each,  in  a  clinical  department,  it  is  necessary  to  have  a 
large  corps  of  assistants.  Especially  is  this  true  as  the  older 
lecture  method  is  more  and  more  replaced  by  recitations,  con- 
ferences and  practical  work  at  the  bedside,  in  the  laboratories 
and  dispensary.  Even  if  it  were  advisable  to  have  the  entire 
department  on  a  full-time  basis,  the  expense  in  certain  de- 
partments would  be  enormous  and  the  plan  therefore  imprac- 
tical. In  addition  to  the  group  characterized  above  as  under 
Plan  2,  the  conduct  of  hospital,  dispensary  and  school  re- 
quires additional  assistance  from  men  giving  only  part  of  their 
time  to  hospital,  dispensary  and  school.  The  extent  to  which 
they  are  used  should  vary  with  the  ideas  and  plans  of  the  re- 


spective  directors,  provided  they  are  not  made  an  essential 
part  of  the  hospital  organization. 

The  salary  of  the  men  on  the  Plan  2  basis  should  be  suffi- 
cient to  make  them  independent  of  any  private  work  and  that 
of  the  director  should  be  enough  to  allow  him  to  assume  the  Salaries 
position  in  the  world  that  he  deserves.  The  men  on  a  part 
time  basis  will  require  a  much  smaller  salary  than  that  of 
the  full-time  men. 

The  head  of  the  department  with  these  associates  should 
form  an  administrative  board,  which  could  relieve  him  of  as 
much  of  the  administrative  details  of  the  hospital  and  of  the 
teaching  as  he  chose.  Unless  he  is  so  relieved  and  protected 
from  the  innumerable  distractions  of  departmental  matters 
he  will  prove  sterile  as  a  producer  and  will  soon  cease  to  be 
the  inspiring  and  stimulating  leader  so  necessary  in  a  depart- 
ment of  this  kind.  These  men  should  have  as  much  time  for 
constructive  thought  and  productive  leisure  as  the  head  of  a 
large  industrial  concern.  By  such  a  combination  and  coordi- 
nation the  department  would  become  a  well-rounded  unit. 
which  should  result  in  great  progress  along  all  three' lines — 
research,  teaching  and  care  of  the  sick. 

V.  Administration. 

There  should  be  a  large  deliberative  body  to  include  all 
teachers  who  are  in  charge  of  courses. 

There  should  be  a  separate  legislative  body  made  up  of  the 
heads  of  the  departments  of  Anatomy,  Bacteriology,  Biologi- 
cal Chemistry,  Neurology,  Obstetrics  and  Gynecology,  Pathol- 
ogy, Pharmacology,  Physiology,  Practice  of  Medicine,  Pedi- 
atrics and  Surgery. 

There  should  be  a  small  adinuiistrative  body  with  whom  the 
Dean  could  advise  as  often  as  was  necessary. 

IV.  Hospital  and  Dispensary. 

The  University  Hospital  must  be  in  close  geographical  and 
functional  relation  to  the  medical  school.  Proximity 

It  must  be  planned  to  contain  sufficient  beds  to  supply  the   ^^^^  Hospital 
clinical  material  necessary  for  classes  of  100  students.     The 
school   should   then   limit   its   undergraduate   teaching   to   the 


Convalescent 
and  Follow- 
up  Facilities 


Special 
Hospitals 


Vanderbilt 
Clinic 


University  Hospital,  except  where  the  dinical  material  proved 
insufficient,  as  for  instance  at  the  present  time  in  psychiatry, 
tuberculosis  and  infectious  diseases. 

If  the  student  is  to  have  a  complete  picture  of  a  disease, 
and  of  more  importance,  if  the  patient  is  to  be  properly  cared 
for,  a  longer  stay  in  the  hospital  should  be  planned  than  is 
now  the  custom  in  most  of  the  New  York  Hospitals.  The  de- 
mand for  beds  is  so  great  that  patients  are  often  discharged 
as  soon  as  they  are  able  to  stand  the  trip  home  and  before 
they  are  really  able  to  resume  their  home  duties.  This  should 
be  arranged  for  by  providing  good  convalescent  facilities,  a 
good  "follow-up  system"  and  by  a  more  generous  supply  of 
beds.  To  satisfy  these  conditions  there  should  be  200  beds  for 
Medicine,  200  for  Surgery  and  250  for  the  other  specialties. 
The  number  of  beds  in  a  general  University  Hospital  which 
shall  be  assigned  to  each  of  the  specialties  should  be  small,  as 
it  should  aim  to  satisfy  only  the  demands  for  undergraduate 
teaching. 

It  is  hoped  that  later  on  special  hospitals  such  as  the  Sloane 
Hospital  for  Women,  may  be  obtained  adjacent  to  the  Uni- 
versity Hospital,  for  each  of  the  specialties.  As  these  become 
available  the  beds  in  the  general  hospital  assigned  to  that  spe- 
cialty will  be  released  and  would  be  ready  to  satisfy  new  de- 
mands as  they  will  arise.  In  this  way  the  normal  increase 
will  be  accommodated  for  some  years  to  come. 

It  is  hoped  that  the  Vanderbilt  Clinic  will  be  moved  with  the 
school  and  built  on  such  a  scale  as  to  include  the  outpatient 
function  of  that  hospital. 

VII.  Summary. 

The  three-fold  purposes  of  the  School  of  Medicine  are  teach- 
ing, research  and  the  care  of  the  sick. 

To  attain  these  there  must  be : 

(a)   An  intimate  geographical  and  functional  union  with  a 
University  Hospital. 

"  (b)  Such  limitation  of  numbers  of  students  as  will  permit 
the  consistent  pursuit  of  a  definite  policy.  Increasing 
demands  may  be  met  by  a  complete  duplication  of  the 
whole  unit. 


10 


(c)   Reorganization  of  the  main  clinical  departments  on  a 
full-time  basis. 

It  is  therefore  recommended  that: 

(a)  An  organic  affiliation  be  formed  with  the  Presbyterian 
Hospital. 

(b)  That  sufficient  funds  be  obtained  to  furnish  the  neces- 
sary land,  buildings  and  endowment. 

This  plan  represents  the  best  thought  of  the  present  time 
but  will  naturally  be  subject  to  such  modifications  and  changes 
in  future  years  as  larger  experience  may  suggest  and  justify. 


11 


COLUMBIA  UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

asT  1 4  «'' 

^ . 

C28(63S)MS0 

D252 


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